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Analgesia first, then light sedation: RASS and SAS, sedation goals and the daily awakening

  • Assessment

In the ICU, pain is treated first, sedation is kept as light as possible and checked with a scale, and it is paused each day if safe.

Updated

What it is

Many ventilated patients receive analgesics and sedatives. Deep, prolonged sedation is linked to longer ventilation, delirium and higher mortality, so current practice is goal-directed: treat pain first (analgesia first), aim for light sedation that the team sets as a target, measure it regularly with a validated scale, and interrupt sedation every day when the safety screen allows (the spontaneous awakening trial). The bedside nurse measures pain and sedation, gives and adjusts infusions within the order, runs the daily awakening with the team and reports when the patient is too deep, too agitated or in pain. Pain scales for patients who cannot speak (CPOT, BPS) have their own page.

Reference values

  • RASS (Richmond Agitation-Sedation Scale): 10 levels; positive levels describe agitation, 0 is alert and calm, negative levels describe sedation down to no response. It relies mainly on how long the patient keeps eye contact after being spoken to, and takes under 20 seconds.
  • SAS (Riker Sedation-Agitation Scale): 7 levels, from unarousable to dangerous agitation.
  • The sedation target is written in the order (for example «calm, alert or easily roused»); there is no single number for every patient.
  • If the patient cannot self-report pain, a behavioural pain scale (CPOT or BPS) is used: see the pain scales page.

What you need

  • The ordered sedation target and the institutional sedation protocol.
  • The pain scale the unit uses (numeric if the patient can answer; CPOT or BPS if not).
  • The infusion pumps with the drug library, and the record of the last assessments.

How to measure it (and why)

  1. Assess pain first, with self-report if possible or a behavioural scale if not: untreated pain causes agitation that looks like a need for sedation.
  2. Give analgesia as ordered before painful procedures (drain removal, line insertion): pain more than doubles during them.
  3. Measure sedation with the unit's scale at the set times and after each change: a number makes drift visible.
  4. Compare the result with the ordered target and adjust within the order, or report: the goal is the lightest level that keeps the patient safe.
  5. Each day, check the safety screen for the awakening trial with the team: some patients must not have sedation paused.
  6. During the trial, stay close and watch agitation, pain, breathing and vital signs: the trial fails if the patient is unsafe.
  7. If the trial fails, restart sedation at a lower level per protocol and record why: then adjust to the target.
  8. Pair the awakening trial with the breathing trial when the team does so: the two together shorten ventilation.

How to read it

  • A level deeper than the target means a lighter infusion or a call; an agitated level means looking first for pain, delirium or low oxygen.
  • A positive RASS (agitation) with a positive delirium screen is hyperactive delirium; a negative RASS with a positive screen is hypoactive delirium.
  • Watch the effects of each drug class as the protocol sets: low blood pressure and slow heart rate with propofol and dexmedetomidine; high triglycerides with long propofol use; accumulation of benzodiazepines in kidney or liver failure.
  • Opioids given for a long time can cause tolerance, dependence and withdrawal when stopped.

Next step: when to call for help

  • Call at once: a patient much deeper than the target, a new failure to respond, low blood pressure or a slow pulse after a dose or rate change.
  • Call at once: dangerous agitation (pulling at the tube or lines) despite the measures in the order.
  • Report: pain that stays high after the ordered analgesia, a failed awakening trial, or a target that no longer fits the patient.

Test yourself

Think of the answer, then tap the question to see it.

What does «analgesia first» mean in ICU sedation?

Pain is assessed and treated before a sedative is started or increased, because untreated pain can look like agitation.

What does a RASS of 0 describe?

A patient who is alert and calm. Positive levels describe agitation and negative levels describe sedation.

Why is deep sedation avoided when it is not needed?

Deep sedation, especially in the first 48 hours, is linked to longer ventilation, delayed extubation, more delirium and higher mortality.

What happens if a daily awakening trial fails?

Sedation is restarted at a lower level, as the protocol states, the reason is recorded and the dose is then adjusted to the target.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: The ABCDEF Bundle in Critical Care (Marra A, Ely EW, Pandharipande PP, Patel MB) (Critical Care Clinics, author manuscript in PubMed Central, 2017); Sedation for adult ICU patients: a narrative review including a retrospective study of our own data (De Bels D et al.) (Saudi Journal of Anaesthesia, PubMed Central, 2023); Implementation of coordinated spontaneous awakening and breathing trials using telehealth-enabled, real-time audit and feedback (TEACH) (Grissom CK et al.) (Implementation Science, PubMed Central, 2023).

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Representative model, for educational purposes only.